Purpose. To evaluate the effect of positioning errors from setup and from prostate motion during escalated dose conformal prostate irradiation for localised prostate cancer. Methods. Thirteen patients with localised prostate cancer had lateral portal films taken three times weekly during escalated dose conformal prostate radiotherapy. Field placement errors were measured by matching corresponding bony landmarks to the simulator film. Prostate motion at the base, mid-gland and apex was measured by imaging the displacement of 3 gold fiducial markers implanted into the prostate before therapy. From these measurements a planning target volume (PTV) was derived that allowed for both the prostate motion and field placement errors.

Results. The random isocentre positioning error was 2.2 mm (range 0.2–7.3 mm), and the mean systematic isocentre positioning error was 1.4 mm (range 0.2–3.3 mm).

Mean prostatic motion at the base was anterior 1.5 mm (SD 2.9 mm, range posterior 11.8 mm to anterior 16.8 mm), and superior 0.2 mm (SD 2.1 mm, range inferior 6.8 mm to superior 10.8 mm). At mid-gland it was anterior 0.6 mm (SD 2.4 mm, range posterior 7.2 mm to anterior 9.2 mm). At the apex it was posterior 0.3 mm (SD 2.1 mm, range posterior 7.9 mm to anterior 9.4 mm), and superior 0.5 mm (SD 2.1 mm, range inferior 6.7 mm to superior 10.2 mm).

The margin of PTV about the prostate needed to give a 99% probability of the GTV remaining within the 95% isodose line during the course of therapy for these patients is superior 5.8 mm, and inferior 5.6 mm. In the anterior and posterior direction, this margin is 7.2 mm at the base, 6.5 mm at the mid-gland and 6.0 mm at the apex.

Conclusions. Systematic setup errors were minimised by patient immobilisation and real-time corrections of setup errors. Prostate motion contributes the largest source of error, and this motion is greatest at the base of the gland compared to the apex. A non-uniform planning margin will improve target coverage while limiting normal tissue exposure. Fiducial markers implanted in the prostate improved quality assurance for radiation delivery by allowing confirmation of organ position within the treatment field over the course of therapy.

The aim of this retrospective study is to develop an evidence-based approach to managing radiation induced skin reactions. A Clinical Guideline Development Group was established to undertake a systematic review of literature and a survey of cancer centres with the objectives of highlighting and recommending best practice. Thirty-one papers were reviewed using the United States Health Care Policy and Research and Scottish Intercollegiate Guidelines Network criteria and 42 United Kingdom Cancer Centres responded with a mix of guidelines and information about skin care assessment and advice. The evidence base for the findings is mainly levels II, III and IV.

Although perceived as common, the incidence of skin reactions has not been quantified. There is little evidence of consistent assessment of acute reactions and the survey data shows that the use of a scoring tool such as the Radiation Oncology Group criteria (RTOG/EORTC 1985) is rare. It also demonstrates that advice to patients is variable and sometimes contradictory. Appropriate and timely information is essential to relieve anxiety and reduce problems.

There appears to be a place for the use of creams in the management of early (RTOG/EORTC 0,1, 2a) skin reactions and in delaying the onset of subsequent skin breakdown, however this evidence is not clear and several of the studies identified some allergic reactions to creams. The intervention used varies between departments and individual patients and is ad hoc rather than based on firm evidence.

For reactions graded RTOG/EORTC 2b and 3, evidence from wound care literature suggests the use of hydrocolloids or hydrogels which are founded on moist wound healing principles. No evidence could be found to support the management of RTOG 4.

The study recommends the development of a clinical guideline encompassing factors affecting the onset of reactions, assessment and management principles, and patient information and makes suggestions for much needed further research.

Palliative radiotherapy represents a substantial workload of a radiotherapy department. This paper provides an overview of a unique service designed to minimise the time between consent and delivery of radiotherapy for palliative patients. In common with other patient-focused care initiatives, this has been achieved by innovative and radically redesigned work practices. Through role development therapeutic radiographers can perform simple palliative treatments. Utilising dedicated equipment they cover all stages of the treatment process, from patient booking through to the end of treatment, providing seamless care for the patient and significant benefits for the department. Auditing the accuracy of simulator radiographs performed by radiographers alone tested the validity of providing simulation of palliative treatment without medical support. The results show 90% required no change with only 1% rejected due to radiographer misinterpretation. The remaining 9% required further information to be supplied by the medical staff. Evaluation of this service included patient and medical staff satisfaction surveys. The results of both were very positive with 100% of medical staff satisfied with the service and all patients rating the service from good to excellent. This project has more than achieved its targets.

There is a large evidence base around prostate cancer. Most of this concentrates on which stages of the disease to treat with which modality. The purpose of this study is to try and determine from the literature an evidence based radiotherapy treatment technique. The evidence is examined on prostate and patient motion, the effect of bladder and rectum filling, patient positioning and error detection with portal imaging. The technique derived is patient supine or prone with empty bladder and bowel. A simple leg immobilisation device is recommended, with set-up to couch height. The required margins are 13.2 mm laterally, 18 mm anterior-posteriorly and 21.3 mm cranio-caudally using a three-dimensional margin recipe. It is shown that an intensive portal imaging routine is required to demonstrate that systematic set-up errors are below 5 mm.

This study aims to examine two related contemporary issues in cancer care; why people with cancer use complementary therapies (CM) and what lessons there may be in this for Cancer Centre Services. The report is presented in two parts. Part 2 is in the current issue and Part 1 was published in the previous issue (Journal of Radiotherapy in Practice 2000; 2(1): 45–51). In Part 1, the main questions for the study were identified and contextualised within the current literature on complementary therapy use. In Part 2 the method, results and analysis the survey and interviews are explored. Of the patients attending the Leicestershire Cancer Centre, 148 returned questionnaires of whom 14 were interviewed in three separate focus groups. Patients from a cancer patient self help group were also interviewed as a fourth focus group. The qualitative data enabled a deeper analysis and evaluation of the quantitative data to be made. The discussion of the data places the main questions asked by the study into a wider context, including the Calman-Hine Report and patient-centred care. The conclusions are that although a significant minority of patients (13%) were using CM at the time of the survey a significant majority of respondents (73%) identified a role for CM alongside conventional cancer treatment and 78% responded that staff at the Cancer Centre should be trained to advise them on the use of CM. The respondents acknowledged the resource and educational implications for Cancer Centres but stated that equal status should be given to care and cure in managing malignant disease. This in line with the Calman-Hine Report. Far greater numbers of patients may use CM if appropriate levels of resources and information were available. The findings indicate that integration of CM could assist in promoting future improvements in quality of survival and patient-centred care as identified by Caiman-Hine and other recent health policy initiatives.