The Pivotal Role of the Therapeutic Radiographer/Radiation Therapist in Image-guided Radiotherapy Research and Development

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.

A retrospective study on improving the accuracy of radiotherapy for patients with breast cancer with lymph node metastasis using Styrofoam

BACKGROUND

To retrospectively analyze the accuracy of radiotherapy using cone beam computed tomography (CBCT), Styrofoam fixation, and breast bracket fixation in the chest wall target area and supraclavicular lymphatic drainage area (supraclavicular target area) of patients with breast cancer.and compare the setting efficiency and comfort satisfaction.

PATIENTS AND METHODS

A total of 65 patients with postoperative lymphatic metastasis of breast cancer, including 36 cases of Styrofoam fixation and 29 cases of breast bracket fixation, were recruited from March 2021 to August 2022 and retrospectively analyzed. All the patients underwent CBCT scans weekly, and the setup errors of the chest wall and supraclavicular target volume were compared and recorded. The planning target volume (PTV) margins of the two groups were calculated using the correlation MPTV = 2.5Σ + 0.7σ. The setup time and comfort satisfaction scores of the two groups were recorded and analyzed. The correlations among errors in each direction were analyzed using the Pearson correlation analysis.

RESULTS

There was a significant difference in the left-right direction (X) axis of the chest wall target area between the Styrofoam and breast bracket groups (1.59 ± 1.47 mm vs. 2.05 ± 1.64 mm, P = 0.012). There were statistical differences in the ventrodorsal direction (Z) and bed angle of the supraclavicular target area, the data were (1.36 ± 1.27 mm vs. 1.75 ± 1.55 mm, P = 0.046; 0.47 ± 0.47° vs. 0.66 ± 0.59°, P = 0.006, respectively). In the X, Y, and Z directions, the respective PTV margins of the two groups in the chest wall target area were 5.01 mm, 5.99 mm, and 5.47 mm in the Styrofoam group, while those in the breast bracket group were 6.10 mm, 6.34 mm, and 6.10 mm, respectively. Moreover, the PTV margins of the supraclavicular target in the three directions were 3.69 mm, 3.86 mm, and 4.28 mm in the Styrofoam group, while those in the breast bracket group were 3.99 mm, 3.72 mm, and 5.45 mm, respectively. The setup time of the two groups was 3.4 ± 1.1 min and 5.5 ± 3.1 min (P = 0.007). The subjective comfort satisfaction scores of the two groups were 27.50 ± 1.24 and 25.44 ± 1.23 (P < 0.001).

CONCLUSIONS

The application of Styrofoam fixation in radiotherapy of breast cancer in the supraclavicular lymph node area has several advantages as compared to breast bracket fixation, including higher positioning accuracy, smaller external expansion boundary, improved work efficiency, and patients' comfort, which might provide a reference for clinical work.

Older adults and the unique role of the radiation therapist: Future directions for improving geriatric oncology training and education

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This article reviews the status quo of the available evidence and guidance for geriatric oncology clinical practice, training and education for radiation therapists worldwide.

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We explore the unique clinical role that radiation therapists play in the management of older adults undergoing radiation therapy.

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We define multiple clinical care points in which the radiation therapists role could potentially expand or specialise into geriatric screening, assessment and intervention to optimise the care of older adults.

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Current GO educational offerings and future directions to improve RTT knowledge and skills around caring for older adults are outlined.

There is widespread recognition that the provision of high quality, appropriate and equitable care to older adults with cancer is a growing challenge in oncology practice. Radiation therapy (RT) is an effective and localised treatment that represents an attractive curative or palliative option for many older adults, and radiation therapists (RTT) play an important role in the delivery, support and quality of care for people during RT. The need to develop an evidence-based, global approach to improving all radiation oncology (RO) professionals’ knowledge and clinical practice in geriatric oncology (GO) has been previously identified. This article specifically focusses on the status quo of GO clinical practice and education for RTT worldwide. We explore the unique clinical role that RTT play in the management of older adults with cancer and define multiple clinical care points in which RTT could potentially participate in geriatric screening, geriatric assessment and intervention to optimise the care of older adults, with a focus on dementia. Directions for future efforts to improve the knowledge and clinical skills of RTT in caring for older adults are discussed.

Images and images: Current roles of therapeutic radiographers

INTRODUCTION

Therapeutic radiography is a small profession and has adapted in response to advanced techniques. An increase in on-line adaptive MRI-guided radiotherapy (MRIgRT) will require role extension for therapeutic radiographers (TRs). This study will investigate the current role description for TRs and the activities they currently undertake with regards to MRIgRT.

METHOD

A training needs analysis was used to ask TRs about their current roles and responsibilities and essential skills required for MRIgRT. For the purposes of this paper, the authors present the results from the demographics of the individual, their current job title with roles and responsibilities, and experience with decision making and image assessment. Descriptive statistics was used to analyse the data.

RESULTS

261 responses were received (n = 261). Only 28% of job titles listed contained the protected title of 'therapeutic radiographer'. Advanced clinical practice roles were expressed by participants indicating that if a service need is presented, emerging roles will be created. Variation existed across the standardised roles of TRs and this discrepancy could present challenges when training for MRIgRT. TRs are pivotal in image verification and recognition on a standard linac, and skills developed there can be transferred to MRIgRT. Decision making is crucial for adaptive techniques and there are many skills within their current scope of practice that are indispensable for the MRIgRT.

CONCLUSION

It has been demonstrated that TRs have a range of roles that cover vast areas of the oncology pathway and so it is important that TRs are recognised so the pivotal role they play is understood by all. TRs have extensive soft-tissue IGRT knowledge and experience, aiding the evolution of decision-making skills and application of off-protocol judgments, the basis of MRIgRT.

IMPLICATIONS FOR PRACTICE

Role development and changes in education for therapeutic radiographers.

Qualitative evaluation of the role of RTTs IGRT specialists and their influence on treatment delivery

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Radiation Therapists specialised in image-guided radiation therapy (RTT spIGRT) experience their role positiveltly.

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The RTT spIGRT role is perceived to have a positive influence on radiotherapy treatment delivery.

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A legal framework to provide formal RTT training and continuous education in order to increase radiotherapy treatment quality is of utmost importance.

Purpose

The study aims to investigate qualitatively how Radiation Therapist IGRT specialists (RTT spIGRTs) experience their role and whether they have an impact on the treatment delivery.

Methods

Eleven RTTs, i.e. six RTT spIGRTs and five RTTs not specialised in IGRT (RTTs noIGRT) were interviewed during October and November 2020. RTTs noIGRT having knowledge of the daily practice before and after the creation of this RTT spIGRT role, served as control group capable of weighing its impact on the work environment. A qualitative method using face-to-face semi-structured questionnaires was used. Interviews lasted approximately 10–20 min, and were after coded and analysed for thematic content.

Results

Five themes and twelve sub-themes were drawn from the analysis. RTT spIGRTs experience their role positively, despite the limited role perception and different work experiences. The implemented role increased autonomy and facilitated decision-making and Radiotherapy (RT) treatment delivery.

Interviewees considered the new role useful to very useful. The raised concerns are related to a bigger role involvement and improvement, with focus on visibility, regular meetings and training. Interviewees considered the RTT spIGRT role to have an influence on the treatment delivery when properly carried out.

Conclusion

RTT spIGRTs experience their role positively. Their knowledge confidence seems to rely on the training received. The RTT spIGRT role is perceived to have a positive influence on the treatment delivery. Continuous follow up and training were amongst the suggested solutions to improve the RTT spIGRT’s role. This study stresses the urgent need for a legal framework to provide formal RTT training and continuous education in order to increase RT treatment quality.

Advanced practice roles of therapeutic radiographers/radiation therapists: A systematic literature review

INTRODUCTION

Advances in Radiotherapy (RT) technology and increase of complexity in cancer care have enabled the implementation of new treatment techniques. Subsequently, a greater level of autonomy, responsibility, and accountability in the practice of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) has led to Advanced Practice (AP) roles. The published evidence of this role is scattered with confusing terminology and divergence regarding the perception of whether a specific role represents AP internationally. This study aims to establish an international baseline of evidence on AP roles in RT to identify roles and activities performed by TR/RTTs at advanced level practice and to summarise the impact.

METHODS

A systematic PRISMA review of the literature was undertaken. Thematic analysis was used to synthesise the roles and associated activities. Six RT external experts validated the list. The impact was scrutinised in terms of clinical, organisational, and professional outcomes.

RESULTS

Studies (n = 87) were included and categorised into four groups. AP roles were listed by clinical area, site-specific, and scope of practice, and advanced activities were organised into seven dimensions and 27 sub-dimensions. Three most-reported outcomes were: enhanced service capacity, higher patient satisfaction, and safety maintenance.

CONCLUSION

Evidence-based AP amongst TR/RTTs show how AP roles were conceptualised, implemented, and evaluated. Congruence studies have shown that TR/RTTs are at par with the gold-standard across the various AP roles.

IMPLICATIONS FOR PRACTICE

This is the first systematic literature review synthetisising AP roles and activities of TR/RTTs. This study also identified the main areas of AP that can be used to develop professional frameworks and education guiding policy by professional bodies, educators and other stakeholders.

Competency level in radiotherapy across EU educational programmes: A cross-case study evaluating stakeholders' perceptions

INTRODUCTION

The education of Therapeutic Radiographers (TRs) is regulated in some countries but is not standardised across the EU, leading to differences in competencies between and within member states. This study aimed to explore stakeholders' perceptions regarding underdeveloped competencies of TRs practising on the linear accelerator, identified in a previous study by the same research team.

METHODS

Interviews with stakeholders from four countries (selected based on the characteristics of their degrees) were performed as part of this cross-case study. Stakeholders were asked to provide their perception regarding the least developed competencies identified in a previous study.

RESULTS

The 27 stakeholders confirmed that Pharmacology, Quality Assurance (QA), Management and Leadership, Research (from the previous study) were underdeveloped and identified Image Verification and Critical Thinking as additional underdeveloped competencies. Suggested causes included: lack of regulation of required competencies at the national level, lack of training dedicated to radiotherapy (RT) (taught within generic modules) and lack of time within the degree programme. The ideal academic level to develop these competencies and whether they are essential varied between country and stakeholder.

CONCLUSION

It is essential to regulate learning outcomes at the national level to ensure a high level of care is provided to all RT patients and, ideally, standardise it across Europe. Education institutions should review their curricula to ensure that sufficient time is dedicated to RT and that the essential competencies are developed. Due to time constraints within some programmes, some competencies must be developed after graduation.

IMPLICATIONS FOR PRACTICE

Lack of regulation of learning outcomes (at European level and national level in many countries) and lack of RT-specific training lead to underdeveloped competencies that may compromise patient care.

Adapting for Adaptive Radiotherapy (ART): The need to evolve our roles as Therapeutic Radiographers

OBJECTIVES

4D Adaptive Radiotherapy (4D-ART) has been stated as the future baseline standard-of-care for technical radiotherapy. Its goal is to optimise radiation dose received by 'adapting' to changes 'seen' in each individual patient, for each treatment delivery (fraction), throughout each treatment delivery. The drive for technological developments to achieve this is ongoing. To enhance the potential benefits, we should consider other aspects of the processes needed: How do changes in clinical practices and processes affect the role of the Therapeutic Radiographer? The aim is to raise the need to explore questions of Therapeutic Radiographers roles and responsibilities within 4D-ART.

KEY FINDINGS

Moving from using current predictive strategies (such as plan-of-the-day) to being able to dynamically adapt (real-time/4D-ART) for patient changes requires rapid clinical judgements to be made. The question becomes 'who makes these decisions'? Currently Therapeutic Radiographers maybe ideally placed for this. Dynamically adaptive radiotherapy requires Radiographers to have clinical decisions-making skills and authorities within the multi-professional team (MPT). It is not sufficient to train radiographers in the 'how' to use 4D-ART techniques and technologies; the ability to make good clinical judgments comes from understanding the principles supporting this concept by understanding the 'why'.

CONCLUSION

To support future service needs and ongoing developments within ART, Radiographer's roles need to adapt and evolve, as well as the way their role is perceived within the MPT. We need to provide Radiographers with the education required, abilities and authorities to act.

IMPLICATIONS FOR PRACTICE

Role revision is required to include greater responsibility for clinical decision making for implementing 4D-ART practices.

A decision tool for radiographer-led abdominal image-guided stereotactic ablative body radiotherapy - Experience from a single institution

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A CBCT decision tool was developed for radiographer-led IGRT for abdominal SABR.

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This tool increased the confidence of radiographers undertaking online CBCT IGRT.

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Median online review time was reduced by 1m 8s.

A decision tool for radiographer-led image-guided radiotherapy (IGRT) using cone-beam CT (CBCT) for abdominal stereotactic radiotherapy was developed and successfully implemented in a single department. The confidence of 7 therapeutic radiographers when undertaking online CBCT review increased, and the pooled median online match time was reduced by 1 m 8 s. While this may be advantageous for abdominal SABR, further evaluation of this work in a larger cohort is required to validate these results.

[Cooperation protocol and advanced practice, an evolutionary perspective for the French radiation therapist]

For several years, the profession of radiographer has been unattractive and is in search of professional recognition. Increasingly complex therapeutic and diagnostic evolutions forces professionals to develop their skills to ensure quality and safe care for all patients. The primary role of the radiographer is to support patients and to accompany them during their examination or treatment, combining caregiver and technician's roles. Transversal missions and delegation of tasks are inherent to the profession but are not widely recognized. Cooperation between radiotherapy professionals is a response to offer the therapeutic radiographer/radiation therapist (RTT) opportunities in terms of attractiveness, career prospects, and increased skills. In radiotherapy, advanced practice activities already exist in some departments but require regulatory adjustments, in particular regarding the redistribution of the roles of RTT but also the status of these professionals. The formalization of these practices can be largely inspired by the many feedbacks around the world. This article aims to reflect the evolution's perspectives in the career of an RTT and on the valorisation of this profession in the current context.

Clinical academic radiographers - A challenging but rewarding career

OBJECTIVES

To explain what a clinical academic career can be, what it can lead to for the individual, profession and most importantly the patient, and why these roles are so important to radiography.

KEY FINDINGS

Multiple challenges to the adoption of clinical academic careers exist, including achievable measurable outcomes, visibility & senior support, and balancing different time demands. Equally the rewards are wide ranging and can advance both the individual and profession through role extension opportunities, increased career progression, patient benefits, and academic and research skills.

CONCLUSION

Clinical academic careers can provide advantages for the individual, department, profession and most importantly the patient with advanced clinical practice through evidenced based research.

IMPLICATIONS FOR PRACTICE

Improving clinical academic careers within Radiography will promote research participation and increase radiographic roles in patient-centred research delivery and development. Combining evidenced based research with academic skills will lead to improved patient care and better clinical outcomes.

Diversity in radiation therapist/therapeutic radiographer (RTT) advanced practice (AP) roles delivering on the four domains

INTRODUCTION

Advanced practice roles are well documented, and continue to respond to the changing landscape in radiotherapy and oncology. In the UK the highest level of AP for the therapeutic radiographer/radiation therapist (RTT) is the consultant radiographer. These posts should meet the four domains of practice, as set out in national guidance. Here we aim to describe well established roles that meet this criteria, and provide subgroups of examples.

METHODOLOGY

Three AP post holders with over 10 years AP experience completed a questionnaire adapted from the consultant radiographer toolkit. These were completed in conjunction with guidance and framework documents. The examples were to demonstrate how they achieve a high level of practice in clinical and expert practice; professional leadership and consultancy; education, training and development; and practice and service development, research and evaluation. Participants then categorised results to add subgroups to each domain.

RESULTS

The questionnaire was completed by three RTTs specialising as a lung consultant radiographer (LCR), a neuro-oncology consultant radiographer (NCR) and a lead research radiographer (RR). Each post holder described how they meet the criteria by discussing the benefit they make to their profession, department and patients. All posts had examples for all criteria, achieving consultant practice. Clinical and expert practice was the dominant domain for the clinical specialist posts, and professional leadership and research evaluation was the strongest domains for the RR.

CONCLUSION

All three consultant RTTs have demonstrated expert practice with clear and transparent examples of their professional practice which evidence the four domains of consultant practice. Following two decades of AP practice for RTTs there is a need to be strategic in the development of future posts with a prospective view on succession planning that safeguards their longevity.