Intensity-modulated radiootherapy (IMRT) is being rapidly embraced as a radiotherapy technique in many cancer centres across the world. This paper aims to highlight the reported problems associated with the use of IMRT for the treatment of head and neck cancer. Specific areas of concern that are mentioned are the identification of tumour volumes, reproducibility of treatment, issues of tumour resistance and tumour recurrence. Radiotherapy departments are advised to make haste slowly when considering the implementation of this technique.

Recently published evidence has shown an improvement in locoregional control and a survival advantage in the treatment of squamous cell carcinomas of the head and neck (SCCHN) using cetuximab, a monoclonal antibody that inhibits the tumour-promoting mechanism of the epidermal growth factor receptor (EGFR). In a large randomised trial, cetuximab was delivered concurrently with radiotherapy and compared to radiotherapy alone in locally advanced SCCHN. The trial showed that the addition of cetuximab offers improved locoregional control and survival without enhancing acute toxicity compared to radiotherapy alone. These exciting results have the potential to change standard head and neck cancer practice, impacting on head and neck cancer services provided by oncology departments and multidisciplinary working.

This article aims to define the mechanism of action of cetuximab, critically appraise the evidence for the use of cetuximab within Oncology departments for SCCHN, and critically evaluate how cetuximab may impact on current practice. Future possibilities and trials to assess the use of cetuximab within clinical practice will also be discussed.

Purpose: The aims of this study were to describe the scope of practice of the radiotherapy ’on treatment’ review radiographer. This included trying to gain an insight in to what knowledge, skills and characteristics are needed to operate in this role extension and to establish whether the role requires skills in areas of patient care and support which are beyond the generic training of a treatment floor therapy radiographer.

Method: A qualitative grounded theory methodology was employed using semi-structured interviews with ’on treatment’ review radiographers from three different departments. The departments were selected to maximise the amount of data collected, consequently they were chosen due to the differences in the way their review service was set up. This ranged from full time, to team led, to part time review. Using coding and constant comparative analysis based on grounded theory, categories were developed describing attributes of the role.

Results: The scope of practice and challenges of the role varied slightly between the departments. The core categories needed to operate in the role were identified as knowledge, listening skills and characteristics with sub categories of self-reflection, interpersonal skills and attitudes.

Conclusions: To be a review radiographer requires advanced knowledge at Masters level, with well developed listening and interpersonal skills and enjoyment of the people side of the profession. These skills need to be regularly practised, updated and reflected upon. The requirements for further training needs are noted and recommendations for further research are identified along with the limitations of this research. The role appears to require knowledge and skills in areas of patient care and support, which are above the level of practice of a treatment floor therapy radiographer.

Introduction: The use of radiotherapy, alone or in conjunction with surgical resection, is common in treating head and neck tumours. However, ionising radiation induces unavoidable changes in the surrounding normal tissues, causing severe complications. Therefore, we decided to study different effects of radiotherapy on gingiva and oral mucosa.

Methods and Materials: This prospective analytical study was performed on 30 patients with head and neck cancers referred to the radiotherapy department of Ghaem Hospital from March to October 2006. Data were collected by means of interviews, clinical examinations and patients’ medical file investigation. The impact of different dosages of radiation on gingiva and oral mucosa was investigated. Data analysis was performed using general linear model (GLM), Cochran and multivariate analysis of variance (MANOVA) tests via SPSS V. 11.5 software.

Results: A direct relationship between increase in radiation dosage, irritation of oral mucosa, ulcer development and mucositis was observed. But there was no significant relationship between NUG (necrotising ulcerative gingivitis) and perlèche and radiation dosage. Periodontal index (PI), gingival index (GI) and papillary bleeding index (PBI) were increased, but due to limited time of study (6–7 weeks), no change in gingival recession was observed. Plaque index (PLI) decreased during treatment process because of oral hygiene instructions.

Conclusion: The oral and periodontal health status of head and neck cancer patients before and during radiotherapy has been described in this article. The authors believe that prevention or reduction of side-effects of radiation should be an integral part of treatment as they may have tremendous effect on the patient's quality of life. This study supports the need for dental assessment and treatment planning before radiation therapy.

Dosimetric changes caused by the positional uncertainty of centring a small electron cutout to the machine central beam axis (CAX) of the linear accelerator (linac) were investigated. First, six circular cutouts with 4 cm diameter were made with their centres shifted off from the machine CAX for 0, 2, 4, 6, 8 and 10 mm using the 6 × 6 cm2 applicator. Then, the percentage depth doses (PDDs) at the machine CAX and cutout centre were measured using the 4, 9 and 16 MeV clinical electron beams produced by a Varian 21 EX linac. The cross- and in-line axis beam profiles were measured at depth of maximum dose (dm) and source-to-surface distance equal to 100 cm using a scanning water tank system and diode detector. When the cutout centre was shifted away from machine CAX for the electron beam with low energy of 4 MeV, the dm, depths of the 80 (R80) and 90% (R90) depth dose at the machine CAX had no significant change (<0.1 mm). For higher energies of 9 and 16 MeV beams, the dm were reduced with 0.45 and 1.63 mm per mm off-axis shift between the cutout centre and the machine CAX, respectively. The R80 and R90 were reduced with 0.7 mm per mm off-axis shift for both energies. When there was a 4 mm off-axis shift, the relative output factors for the 4, 9 and 16 MeV beams were reduced with 0.8, 1.6 and 0.5%, respectively. The isodose coverage of the in-line axis beam profile was reduced when the cutout centre was shifted away from machine CAX. It is important for radiation oncologists, dosimetrists, therapists and physicists to note such dosimetric changes in the electron radiotherapy to the patient, because such positional uncertainty is unavoidable in fabricating an electron cutout in the mould room.

In last few years, adjuvant post-operative radiotherapy and occasionally preoperative irradiation combined with chemotherapy are considered as effective practices to improve disease control and survival in gastric cancer. Yet, chemoradiotherapy result in severe toxicities and radiotherapy practice is a significant contributor. For a recommended median dose of 45 Gy to the treatment volume of stomach and surrounding lymphnode regions, considerable doses are likely to be delivered to liver, kidneys and spinal cord. Few literatures and texts state about the radiotherapy techniques, with recent emphasis on conformal (3-D CRT) or intensity-modulated radiotherapy (IMRT). However, these facilities are not uniformly available in most developing countries where stomach cancer is common. This is a report on practical aspects of radiotherapy techniques and planning which can be utilised as per available settings of a radiotherapy department.

Radiographers are undertaking roles that are a development and extension of what has traditionally been seen as their remit. As with any development, it is important that such changes in practise have a positive rather than negative effect on patient care and patient experience. This article examines patient perception and level of patient satisfaction of an ‘on-treatment review’ conducted by a site-specific advanced practitioner radiographer instead of an oncology doctor. Overall, the results were positive suggesting that such reviews, when conducted by an appropriately trained individual, can enhance patient care and provide a satisfactory level of support during treatment.

The reduction in dose received by normal tissue is essential in radiotherapy to reduce the chance of late side-effects. This is especially true in paediatric radiotherapy as any late-effects can seriously impair the future quality of life experienced by the treated child.

Particle therapy uses high-energy particles to deliver a surgically precise beam of energy to a pre-determined position in the body. Common side-effects associated with conventional radiotherapy (CRT) are considerably reduced, often virtually eliminated, owing to the reduction in dose received by neighbouring healthy tissues, improving future quality of life. The superior accuracy of particles also means the dose can be escalated improving control rates.

Clinical trials, reviews and planning studies have been reviewed to assess the benefits and limitations offered by particle therapy in paediatric treatments. The reduced integral dose and improved conformity is clearly highlighted throughout these studies, demonstrating the potential advantages available with particles when treating paediatric patients.

The data suggest that the advantages experienced with particle therapy result in a significant reduction in the side-effects experienced and therefore an improvement in quality of life when compared with conventional therapy. Owing to the reduction of subsequent sequelae, paediatric patients need to be considered when designing and constructing a particle centre in the UK.

Aims: Recent years have seen an expansion of UK radiotherapy treatment capacity with a drive to reduce radiotherapy waiting times. Consequently, the time available for planning patients is decreasing. In this context, management of treatment planning workflow in the Princess Royal Hospital is described and monthly planning times are presented from September 2003 onwards.

Materials and Methods: After patients are imaged, patient name, unit number and appointments are available to the planning spreadsheet via a link to the radiotherapy information system. The planning spreadsheet is in descending order of appointment date. Treatment planning staff select the first available task, taking account of individual competencies. At plan completion, the patient record is moved to the completed list.

Results: Since September 2003, patient numbers through treatment planning steadily increased from around 90 a month to about 130 currently. Planning times decreased from 11 to 7 workdays.

Conclusions: Workflow through treatment planning is indirectly managed and the approach allows for day-to-day staffing fluctuations and competency levels. There is instant information on planning status for all patients throughout the department, building up a record as part of the work process. Bottlenecks and staff training needs can be analysed by reviewing the historic patient workload.

Inter-observer variations in contouring and their impacts on dosimetric and radiobiological parameters in intensity-modulated radiotherapy (IMRT) treatment for localised prostate cancer patients were investigated. Four observers delineated the gross tumour volume (GTV) (prostate and seminal vesicles), bladder and rectum for nine patients. Contouring done by radiologist was considered as gold standard for comparison purposes and for IMRT plan optimisation. Maximum average variations in contoured prostate, bladder and rectum volumes were 3% (SD = 8.4), 2.5% (SD = 4.12) and 13.2% (SD = 6.77), respectively. The average conformity index for standard contouring set (observer A) was 0.85 (SD = 0.028) and statistically significant differences were observed for observers A–B (p = 0.008), A–C (p = 0.006) and A–D (p = 0.011). Average values of normal tissue complication probability for bladder and rectum for observer A were 0.361% (SD = 0.036) and 1.59% (SD = 0.14). Maximum average tumour control probability was 99.94% (SD = 0.035) and statistically significant difference was observed for observers A–B (p = 0.037) and observers A–C (p = 0.01). Inter-observer contouring variations have significant impact on dosimetric and radiobiological outcome in IMRT treatment planning. So accurate contouring of tumour and normal organs is a fundamental prerequisite to make good correlation between calculated and clinical observed results.

Purpose: To compare the Combifix® immobilization device with a conventional double-leg cushion in terms of patient comfort, therapist feedback and systematic/random error outcomes.

Materials and Methods: This prospective block-randomised crossover study enrolled 18 high-risk prostate cancer patients who received whole pelvic plus prostate radiotherapy. Treatment consisted of a prostate boost with one immobilization device followed by whole pelvic radiation using the other device. Our primary endpoints were device ease-of-use and patient comfort. Secondary endpoints included treatment time and systematic/random error assessments.

Results: While our patients found both devices equally comfortable and easy to use, the therapists preferred the leg cushion for ease of set-up (p = 0.04). Patient treatment time was similar for the two devices. In terms of electronic portal imaging (EPID)-based isocentre shifts, statistically, but not clinically, significant differences in systematic and random errors between the two devices exist in the superior–inferior directions (p ≤ 0.05).

Conclusions: No clinically important advantage was seen with the Combifix® device versus our standard double-leg cushion in terms of patient/therapist preference, patient comfort, and bony pelvic immobilization. However, this research project confirmed the feasibility of mounting a small single-institution randomised crossover technology assessment related to a practical radiotherapy issue.

Aims: Monitoring and reviewing patients during adjuvant radiotherapy for breast cancer is an integral component of care and was until recently a predominantly medical domain. Patients were often reviewed in busy routine breast clinics, for short consultations with a variety of medical staff and with little time to address questions or concerns. Non-medical treatment review clinics, staffed by senior nursing and senior therapy radiographers have been introduced to provide a dedicated, consistent treatment review. This survey was conducted to assess the effectiveness of the non-medical review of these patients.

Materials and methods: This was a prospective survey of all patients attending for breast or chest wall radiotherapy, between 1st July 2003 and 30th June 2004. Patients were invited to complete and return a postal questionnaire related to their treatment and treatment review. Review staff collected data on demographic information, clinical history and treatment intent for these patients at first visit. At subsequent weekly review visits, data were recorded relating to patient assessment, interventions and referrals initiated. Skin reactions were graded using Radiation Therapy Oncology Group scoring tool.

Results: One thousand and ninety-five patient questionnaires were distributed and 865 (79%) were returned. There were high satisfaction scores with the time spent with review staff (99.7%) and the ability to discuss all aspects of treatment and concerns (99.1%). One hundred and ninety-three patients were referred to non-medical staff for additional support. Five hundred and forty-four were referred to medical staff. The majority (437) were planned referrals to their clinical oncologist to prescribe a ‘boost’ or review endocrine treatment and 107 to their general practitioner for routine visits and employment certificates. Review staff data of 1,067 patients showed 342 referrals for treatment and non-treatment related physical problems, 80 referrals for additional information and emotional support. Majority of skin reactions were grade 1 or 2a.

Conclusion: The successful identification of patients’ supportive needs and high patient satisfaction with this service supports the use of this approach.

Introduction: In squamous-cell carcinoma (SCC) of the head and neck, unplanned gaps risk prolongation of the overall treatment time (OTT) and reduction in tumour control. This audit determines whether further acceleration can safely be employed to compensate for missed treatments during accelerated hypofractionated radiotherapy.

Methods: Patients receiving accelerated hypofractionated radiotherapy for SCC of the head and neck were prospectively audited. Outcome measures were OTT, degree of compensation and acute toxicity determined by incidence of grade 3 mucositis, prolonged grade 3 mucositis, grade 3 dysphagia and pain.

Results: In the 87 patients identified, the dose administered was 55 Gy in 20 fractions (81 patients), 50 Gy in 20 fractions (1 patient) and 50 Gy in 16 fractions (5 patients). Of those patients receiving 20 fractions, 94% completed within 28 days. Grade 3 mucositis was seen in 56 patients (64%). Compensating for unplanned gaps did not result in any significant increase in toxicity. Administering 6 fractions/week, as compensation, was associated with a lower pain score (p = 0.003) as was receiving 2 fractions on the same day (p = 0.0004).

Conclusions: Accelerated hypofractionation is tolerable with most patients completing treatment within the planned OTT. When unplanned gaps occur, then compensation by further acceleration is possible.

This research aims to establish the prevalence and aetiology of anxiety and depression in cancer patients within their first 2 weeks of a radical course of radiotherapy. Depression followed by anxiety is the two most frequent psychological disorders experienced by cancer patients. However, these two disorders are frequently undiagnosed and untreated in patients undergoing a course of radiotherapy possibly because the treatment side effects often simulate those of anxiety and depression; the consequences of this can be reduced patient prognosis and increased health care costs. A questionnaire was administered to a sample of 100 eligible cancer patients and this yielded a 68% response rate. The Hospital Anxiety and Depression (HAD) scale was integrated into the questionnaire to accurately establish levels of anxiety and depression in the respondents of the study. The study identified six respondents with clinically significant levels of anxiety (9%) and six with depression (9%); 21% (n = 14) of participants had higher than normal levels of anxiety and 21% for depression (n = 14). Correlations were then identified between levels of psychological distress and the four independent variables; age, diagnosis, adjuvant medication and pain. Four predisposing factors were established—breast cancer diagnosis, age range 40–50 years, the presence of pain and adjuvant chemotherapy regimes.

Objectives: This study is designed to present and evaluate radiobiological-based dose–volume histogram (DVH) reduction schemes to calculate normal tissue complication probability (NTCP) and tumour control probability (TCP) for intensity-modulated radiation therapy (IMRT).

Methods: The proposed DVH reduction schemes were derived for 2 Gy per fraction and prescribed dose per fraction for critical organs and tumours, respectively. Sample computed tomography scans were used to generate two IMRT plans to deliver 54 Gy to PTV1 and 24 Gy to PTV2 via sequential IMRT boost (SqIB) and simultaneous integrated IMRT boost (SIB) plans. Differential DVHs were used to calculate effective volumes using published values of related parameters of critical organs and prostate.

Results: NTCP values for bladder were almost zero for both IMRT plans. The plots between k and NTCP for rectum and femurs (k = 0.1–1.0) show higher NTCP for SqIB than that for SIB. The TCP decreases with increasing clonogenic cell density and is higher for SIB than that for SqIB for all clonogenic cell densities. The value of α proposed by Brenner and Hall shows very low radio sensitivity of clonogens of the prostate, which gives very low TCP for conventional doses of 70–80 Gy delivered in 7–8 weeks, even for very low clonogenic cell density in the prostate.

Conclusion: The presented DVH reduction schemes have radiobiological bearing and therefore seem to be effective in calculating fairly accurate NTCP and TCP.

Lymphopaenia is the earliest and the most sensitive routinely assessed biological parameter of corporeal radiation exposure in clinical practice; bone marrow, lymph nodes and peripheral blood lymphocyte populations are also at risk. During radical prostate radiotherapy, in 28 patients, the mean peripheral lymphocyte count fell from 1.76 × 109/l (standard deviation (SD) 0.63, 95% confidence interval (conf.) 0.23) to 1.10 × 109/l (SD 0.38, conf. 0.14), (p < 0.05). The question was asked as to whether intensity-modulated radiation therapy (IMRT) by TomoTherapy would cause more lymphopaenia than three-field conformal radiotherapy, bearing in mind the ‘low dose bath’ effect of IMRT and the long ‘beam-on’ times. Thirteen patients receiving three-field conformal radiotherapy experienced a fall in peripheral lymphocyte counts from 2.02 (SD: 0.62. conf. 0.43) to 1.17 × 109/l (SD: 0.47, conf. 0.26) after 34–38 Gy, as compared to a fall from 1.6 × 109/l (SD: 0.6, conf. 0.35) to 1.04 × 109/l (SD: 0.3, conf. 0.15) for 15 TomoTherapy patients—non-significant differences. We conclude that for this (approximately) standard, small-volume pelvic radiotherapy and to the dose under scrutiny, we cannot detect differences between the two radiotherapy techniques in terms of the lymphopaenia accruing. Neutrophil counts were similarly non-significantly different.

Background: Breast cancer is the most common cancer and most common cancer cause of death in women aged 20–49 years in Canada. Developing a functional definition of ‘young’ is imperative in assessing and providing appropriate emotional support to the unique body image and sexuality concerns facing ‘young’ women with breast cancer. These concerns require proper assessment in order to provide appropriate interventions.

Aims and objectives: To seek a functional definition of ‘young’ and to determine what body image and sexuality assessment tools and interventions are the most appropriate for young women with breast cancer.

Methods: A literature search was undertaken to determine what body image and sexuality assessment tools and interventions are available and relevant to young women with breast cancer. Also, the assessment and interventions available to this patient cohort in the author's clinic were explored.

Conclusions: Body image and sexuality questionnaires encourage young women and health-care providers (HCPs) to openly discuss these issues. Annon's PLISSIT model is an assessment and intervention strategy that enables HCPs to adequately assess and refer young women to suitable programs such as support groups and counsellors. The multi-disciplinary team should provide continuous emotional assessment and support throughout the cancer journey by collaborating to develop the best interventional strategies to the patient and her family.

As radiation therapy practice evolves with advancing treatment and planning technologies, merging of imaging modalities, changing working models and the advancement to higher education, radiation therapists are frequently finding themselves on the frontline of translating new knowledge into practice. To a large degree, this growing involvement in self-directed original research, with associated dissemination of completed results, has led to an increasing number of therapists being encouraged to pursue an academic path in addition to a clinical career. In Canada, radiation therapists are being appointed as faculty to university departments for the first time. It is heartening that such opportunities are increasing; therapists are able to play a profound role in developing an evidence-based professional body of knowledge while at the same time being recognised for scholarly endeavours. However, despite these many positive steps, barriers and challenges to the development of a scholarly culture for radiation therapists still exist. Part one of this two-part series explores the history of the profession and the subsequent development of a scholarly culture.

Cancerisation of the lobules (CL), the intra-luminal extension of carcinoma from ducts and ductules into the breast lobules, is not often encountered in clinical practice. A retrospective study of eight individuals diagnosed with CL and ductal carcinoma in situ (DCIS) or cancer of the breast between 1999 and 2006 was undertaken to determine the management of the disease and patient outcomes. In most cases, breast conservation surgery with postoperative radiotherapy or mastectomy and systemic therapy were the chosen methods of treatment. None of the patients experienced tumour relapse or progression during a mean follow-up period of 40.6 (range 8–90) months. The management philosophy for this particular neoplastic condition should be based on the understanding that CL, when detected with DCIS or invasive breast cancer, may represent more extensive disease. Moreover, the finding of such histopathology underlines the need for meticulous attention to the resection margins and additional treatment as indicated.

Purpose: The purpose of this review was to explore the literature on the use of hyperthermia (HT) in advanced breast cancer.

Methods: A literature search was conducted to obtain information from recent trials of HT and/or chemotherapy (CH) and radiotherapy (RT) for patients with locally recurrent breast carcinoma. Issues concerned with patient compliance and side effects have also been reviewed and future recommendations for research made.

Results: Results of recent trials have demonstrated promising outcomes for HT and RT in combination, particularly for recurrent disease to improve local control (LC). There is no evidence, however, to support a positive effect on overall survival.

Conclusions: Despite positive results HT has not been widely embraced, due to financial and logistical limitations. Future recommendations include larger, randomised, controlled studies and the development of temperature mapping to avoid potentially limiting HT blisters.