Background: Patient satisfaction surveys conducted in English exclude respondents who are not proficient in the English language. This makes it difficult to assess whether health care services provided are culturally appropriate. This study aims to evaluate the level of satisfaction for Chinese speaking patients who received radiation treatments at the British Columbia Cancer Agency, Vancouver Centre in Canada.

Patients and Methods: Chinese patients were given a translated patient satisfaction survey on a voluntary basis to complete at the end of treatment. Contingency table analysis using the Pearson chi-square test or Fisher’s exact test was performed at 5% significance level for all analyses. Logistic regression analysis was conducted to investigate whether complete satisfaction with an aspect of care influenced overall satisfaction with services provided by the RT team.

Results: The level of satisfaction in Chinese speaking patients was lower compared to English speaking patients. The results from the Chinese survey also identified the importance of treatment patients with courtesy and providing them with a pleasant wait area.

Conclusions: Despite a language barrier, Chinese speaking patients still contributed to improvement initiatives at the Vancouver Centre. Efforts to ensure a culturally appropriate environment and provision of services include recruitment of staff members who reflect the cultural diversity of the community serviced, use of interpreter services or bilingual health providers for clients, use of linguistically appropriately education materials, and health care settings that is pleasant and respects the cultural diversity of the population serviced. This assessment provided a better understanding of whether services at the Vancouver Centre were culture appropriate.

Introduction: PET–CT scans are commonly used for the purpose of gross tumour volume (GTV) delineation in head and neck cancers. Qualitative visual methods (QVM) are currently employed in most radiotherapy departments but these are subject to inter- and intra-observer variability. Quantitative thresholding methods which appear in the published literature are evaluated with respect to their reliability for delineation of GTVs in head and neck cancers.

Discussion: Image segmentation involves the application of a distinct value to all pixels or voxels in an image dataset. This is a complex process affected by numerous variables. Some of the following segmentation thresholds may be applied to automatically delineate specified regions. Standardised uptake value (SUV) is commonly used to apply a threshold for GTV delineation, however this leads to inappropriately large GTVs. A further common quantitative threshold is based on the maximum signal on the PET image relative to the background uptake, known as signal to background ratio (SBR). This method generates GTVs that correlate well with surgically removed tumour volumes. Applying a fixed threshold of a percentage of the maximal intensity uptake is also documented in the literature but was found to be unsuitable for the purpose of head and neck GTV contouring. Systems based on the physical features of the PET-CT images are also discussed and are found to produce very promising results.

Conclusion: A number of quantitative techniques are evaluated and currently the most suitable is found to be SBR, however even this method was not found to be entirely reliable. More promising techniques need further evaluation before they could be implemented clinically and a Radiation Oncologist or Nuclear Medicine Radiologist must still validate all GTVs produced by quantitative methods.

The idea of the present work was to investigate general features of the vertical travel of the treatment table in different configurations and the limitations of an optimised alignment. The investigations were carried out on two tables for different load cases, lateral positions and turntable angles. A wire was held vertically nearby the rotational axis of the table. The wire was used as reference in the investigations. A digital USB-microscope was attached to the tabletop. An orthogonal set of images of the wire was acquired at different vertical table positions. By analysing the images the vertical travel accuracy of the table was extracted. The two tables were found to travel linearly with the same characteristics over the full range of 110 cm with deviations less than 0.5 mm relative to a straight line. A divergence from a vertical travel above 0.5 mm was found to originate from misalignment. An alignment procedure to attain the optimal vertical performance with a minimum of inclination was presented. This procedure must be relayed on objective measured data of the travel with uncertainties far beyond 0.5 mm. Our suggested experimental method was found to have the potential to obtain the required data.

Radical radiotherapy to the bladder for muscle-invasive bladder cancer is a challenging treatment to plan and deliver because of organ mobility and its varying volume. The dynamic target volume can be tracked with imaging during the treatment course, enabling an adaptive response and adjustment of the patient’s individual treatment plan. This article summarises the difficulties encountered when treating the bladder, different approaches to patient imaging and adaptive radiotherapy techniques. Ultimately these technological advances support the delivery of a personalised treatment plan to ensure optimal dose delivery to the tumour and simultaneous sparing of adjacent normal tissue.

Introduction: Radiotherapy-induced hyposalivation encourages oral Candida colonization that often leads to oral/pharyngeal candidiasis. The objective of this study was to identify the Candida species in lesions of oropharyngeal candidiasis in patients undergoing radiotherapy for head and neck cancers and to find out antifungal susceptibility pattern.

Material and methods: Swabs were collected from 60 patients who developed lesions suggestive of oral candidiasis at the end of 1st week of radiation therapy. Antifungal susceptibility of each of the isolated species was done using disc diffusion method following CLSI guidelines.

Results: Candida was isolated in 13 cases. C. albicans (7) was the most predominant species; a small number of other species have also been identified. Few strains (3) of Candida showed variable resistance to the commonly used antifungal drugs.

Discussion: The colonization of Candida may lead to development of infections with drug-resistant strains, and hence the patients receiving radiation for head and neck cancers should undergo microbiological study for oral candidiasis.

Introduction: Surgery is the treatment of choice in stage I and II non-small-cell lung cancer (NSCLC). In the management of patients who are medically unfit to tolerate surgical intervention or who refuse surgery, radiotherapy is an acceptable alternative. We have performed a retrospective analysis of the effectiveness of radical radiotherapy in patients with early stage NSCLC treated over a period of 4 years.

Methods: Thirty nine patients treated with radiotherapy of radical intent were identified. All patients received hypofractionated radiotherapy with a total dose of 55Gy in 20 fractions.

Results: The median survival of all cases was 29 months. The one and two-year survival was respectively 61 % and 41%. The median survival of patients ≥75 years was 28 months, and age was the only prognostic factor identified in this analysis that affected survival.

Conclusions: The presented survival results are consistent with those from other series published in the literature. At present, radical radiotherapy is often offered to patients with medically inoperable stage I and II NSCLC or those who decline surgery. But there is emerging evidence that some new techniques like stereotactic radiotherapy could be also used in the operable, early stage NSCLC.

Purpose: To investigate the benefits of a regions of interest atlas for radiation therapists (RTTs) to aid in the identification of male pelvic structures in radiotherapy for prostate cancer, post-prostatectomy.

Methods and materials: Recruiting 35 radiation therapists from the Royal North Shore Hospital, a pretest- post-test study design was employed, with the atlas as the intervention. Using two patient CT data-sets, structure identification was scored as correct or incorrect and RT confidence levels were recorded using a visual analogue scale. The number of years of experience of each RT was also documented. Statistical significance was calculated using the Wilcoxon signed ranks test, paired samples t-test and chi-square tests.

Results: A statistically significant improvement was found between the pre-test and post-test in terms of both structure identification (p < 0.001) and confidence (p < 0.001) levels, with use of the atlas. The atlas was of use to staff of varying experience levels. Structures that were not normally used for target volume localisation were the hardest to identify.

Conclusion: Regions of interest atlases should be implemented to help identification of areas of anatomical complexity.

Purpose: Comparison of prostate seed implant treatment plans is currently based on evaluation of dose-volume histograms and doses to the tumour and normal structures. However, these do not account for effects of varying dose-rate, tumour repopulation and other biological effects. In this work, incorporation of the radiobiological response is used to obtain a more inclusive and clinically relevant treatment plan evaluation tool.

Materials and Methods: Ten patients were evaluated. For each patient, six different treatment plans were created on the Prowess system. Plans with iodine-125 used a prescription dose of 145 Gy while plans with palladium-103 used 115 Gy. The biologically effective dose was used together with the tumour control probability and the normal tissue complication probabilities of urethra, bladder, rectum and surrounding tissue to evaluate the effectiveness of each treatment plan. Results from the radiobiological evaluation were compared to standard dose quantifiers.

Results: The use of response probabilities is seen to provide a simpler means of treatment evaluation compared to standard dose quantifiers. This allows for different treatment plans to be quickly compared. Additionally, the use of radiobiologically-based plan evaluation allows for optimisation of seed type and initial seed strengths to find the ideal balance of TCP and NTCP.

Conclusion: The goal of this work was to incorporate the biological response to obtain a more complete and clinically relevant treatment plan evaluation tool. This resulted in a simpler means of plan evaluation that may be used to compare and optimise prostate seed implant treatment plans.

Objective: Two opposed tangential photon beams followed by scar boost with electrons is a common technique for post-mastectomy radiotherapy to the chest wall. However with current advances in x-rays (conformal and intensity modulated radiotherapy), the electrons have gained less attention; and most of the centres are using the conventional electron therapy techniques. Here we share our experience of electron conformal therapy (ECT) and modulated electron therapy (MET) for post-mastectomy scar boost.

Materials and methods: For post-mastectomy chest wall irradiation, 25 patients were treated with ECT and MET in five steps (a) virtual simulation and image acquisition using CT scanner Siemens® followed by (b) data transfer to Coherence Siemens® for contouring of skin, clinical target volume (CTV), planning target volume (PTV) and organs at risk (OARs), followed by (c) forward and reverse planning applying segmented fields using Prowess Panther treatment planning system (TPS) Siemens® and shaping of fields on beam’s eye view (BEV), (d) data transfer to computer assisted fabrication device (Autimo 2D) for lead cut outs and wax blocks and finally (e) quality assurance (QA) and modified treatment delivery.

Results: Apart from energy selection and tumor delineation, the ECT and MET showed maximal sparing of OARs (< 70% of prescribed dose), and improved dose conformity compared to single energy single field plans. Phantom and in vivo dosimetric measurements showed excellent agreement with calculated doses with difference ±2%. Conformity improved little beyond allowing three energies due to energy overlap and field-size constraints and conformity improvement was found at the expanse of dose heterogeneity within the PTV.

Conclusions: ECT and MET is time saving and can be utilised for treating superficial targets to improve the treatment outcome and with better QA; however, efforts are required to design commercially available eMLC (electron multileaf collimators) in modern linear accelerators.

Purpose: To determine disease-free and overall survival of neuroendocrine small cell cancer of cervix treated at the Northern Ireland Cancer centre between 1999 and 2010.

Materials and methods: A retrospective review of all patients diagnosed and treated with neuroendocrine small cell cancer of cervix in Northern Ireland. Details of treatment modality including chemotherapy, radiotherapy and surgery were recorded.

Results: Fifteen patients diagnosed with neuroendocrine small cell carcinoma (NSCC) of cervix were identified between 1999 and 2010, twelve with disease localised to the pelvis and three with metastatic disease. Three-year overall survival for all patients was 65% and disease-free survival was 45% for all patients. In patients with pelvic confined disease 3-year overall survival was 79% and disease-free survival was 57%. Median disease-free and overall survival was 30 and 39.6 months respectively. These survival rates compare very favourably to those reported in the literature. Stage of disease at diagnosis was the main determinant of survival.

Conclusion: Local control and survival can be achieved in NSCC of patients with a combination of irradiation and platinum-based chemotherapy. Stage of disease determines outcomes.

Purpose: To identify the challenges and opportunities that prevent Radiation Therapist (RT) led research at our clinic. Insight gained from this process may lead to strategies which can encourage and support RT research. In this way we can ensure evidence-based practises are promoted by RTs as well as enhancing the professional profile of RTs in the research domain.

Methods: A qualitative approach was chosen for this study. Five focus group sessions were conducted to discuss issues related to research participation within our department. Sessions were audio-recorded and transcribed. Thematic analysis occurred whereby overarching themes were identified, content categories were developed, and summaries were written from these categories. Pre-dominant themes were later presented to the entire radiation therapy department for member checking. Answers to a series of questions were obtained anonymously through the use of iClickersTM (MacMillan MPS, Gordonsville, VA). Further, an open group discussion followed focusing on three key areas (departmental, personal and professional). Initiatives or opportunities that could be implemented to increase research activities were discussed and recorded by a designated note-taker.

Results: Nineteen RTs participated in five focus group sessions. The over-arching themes identified were definition of research, involvement in research and the barriers to conducting research. Member checking confirmed these major themes.

Conclusion: We identified the challenges faced by RTs in the areas of research and development at our centre. This information has given us a greater understanding of the culture of our department and the attitudes to research activities from all groups within it. We aim to use these insights to set-up a framework of support to facilitate increased initiatives. Alongside this support RTs will have a clear understanding of their responsibilities to the organisation that facilitates their research. We anticipate these developments will lead to greater job satisfaction for RTs, increased staff morale and most importantly, the improvement of the overall quality of services we deliver to our patients.

Purpose: Several isotopes are available for low dose-rate prostate brachytherapy. Currently most implants use a single isotope. However, the use of dual-isotope implants may yield an advantageous combination of characteristics such as half-life and relative biological effectiveness. However, the use of dual-isotope implants complicates treatment planning and quality assurance. Do the benefits of dual-isotope implants outweigh the added difficulty? The goal of this work was to use a linear-quadratic model to compare single and dual-isotope implants.

Materials & Methods: Ten patients were evaluated. For each patient, six treatment plans were created with single or dual-isotope combinations of 125I, 103Pd and 131Cs. For each plan the prostate, urethra, rectum and bladder were contoured by a physician. The biologically effective dose was used to determine the tumor control probability and normal tissue complication probabilities for each plan. Each plan was evaluated using favorable, intermediate and unfavorable radiobiological parameters. The results of the radiobiological analysis were used to compare the single and dual-isotope treatment plans.

Results: Iodine-125 only implants were seen to be most affected by changes in tumor parameters. Significant differences in organ response probabilities were seen at common dose levels. However, after adjusting the initial seed strength the differences between isotope combinations were minimal.

Conclusions: The objective of this work was to perform a radiobiologically based comparison of single and dual-isotope prostate seed implant plans. For all isotope combinations, the plans were improved by varying the initial seed strength. For the optimized treatment plans, no substantial differences in predicted treatment outcomes were seen among the different isotope combinations.

A research study was conducted at the radiation oncology department of a large teaching hospital in Ghana, to determine whether the use of a pain questionnaire would facilitate a contribution by the radiation therapists (RTs) to the management of pain in the patients undergoing external beam radiotherapy. The rationale for the study was to test the pain questionnaire as a tool for routine use by RTs and to increase the knowledge and skill of the RTs with regard to pain assessment in order that they could have an effective role in the multidisciplinary approach to pain management.

The pain questionnaire for administration by RTs was adapted as a tool for assessing pain. The tool and the process were tested in a prospective study of 90 participants who willingly consented to participate. The data was analysed as a means of evaluating the questionnaire and learning about pain in this group of cancer patients. The results of this analysis were integrated with the findings from textual data published in a previous paper.

Findings revealed that RTs could administer a limited pain questionnaire and use this for clinical assessment of patients with pain, refer patients who need urgent medical attention to the doctors, monitor the patients receiving radiotherapy and adjuvant chemotherapy as well as provide meaningful suggestions to the multidisciplinary team on the management of pain.

Through this reflective process it is recommended that because RTs have daily contact with patients during external beam radiotherapy treatment and because the majority of cancer patients in the study population experience pain, the RTs should enhance their knowledge of pain and participate in routine pain assessment. Through engagement in this role development the quality of care to the patient population in Ghana will be improved.