Introduction: Benchmarking can be used to improve hospital performance. It is however not easy to develop a concise and meaningful set of indicators on aspects related to operations management. We developed an indicator set for managers and evaluated its use in an international benchmark of radiotherapy centres. The indicator set assessed the efficiency, patient-centeredness and timeliness of the services delivered.

Methods: We identified possible indicators from literature and professionals. Stakeholders’ feedback helped to produce a shortlist of indicators. For this indicator set, data were obtained in a pilot that included four European radiotherapy centres. With these data, the indicators were evaluated on definition clarity, data availability, reliability and discriminative value.

Results: Literature produced a gross list of 81 indicators. Based on stakeholder feedback, 33 indicators were selected and evaluated in the benchmark. Six negatively evaluated indicators were adapted, together with eight positively evaluated indicators 14 indicators seemed feasible. Examples of indicators concerned utilisation, waiting times, patient satisfaction and risk analysis.

Conclusions: This study provides a pragmatic indicator development process for international benchmarks on operations management. The presented indicators showed to be feasible for use in international benchmarking of radiotherapy centres. The pilot identified attainable performance levels and provided leads for improvements.

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.

Background and aims: Current evidence suggests that acupuncture may provide some palliation of the symptoms and side effects of cancer and its treatments. Therefore, consideration of the potential benefit of the introduction of an acupuncture service in oncology at Cornwall was investigated. This study describes the experience of patients using the service.

Methods: Between April 2005 and October 2007, 107 oncology patients experiencing one or more of the following symptoms, such as nausea, vomiting, hot flushes, pain, breathlessness, dry mouth, anxiety, depression, fatigue, diarrhoea, constipation or difficulties in coping, were referred for up to 10 weekly acupuncture treatments. About 103 had acupuncture treatment. This observational study utilised responses to questionnaires and self assessment of symptoms at the start (baseline), on completion of treatment and at two months post-acupuncture treatment.

Results: Complete data were returned for 47 participants. Improvement in vasomotor symptoms was seen in 86% of patients presenting with hot flushes. There was a significant (p = < 0.001) reduction in anxiety following acupuncture. The mean difference between scores on the Fatigue Scale (18) across the study period showed improvement in patients experiencing fatigue (p = 0.039).

Conclusion: An acupuncture service for Oncology is practicable and is of benefit to patients. A future randomised controlled trial focusing on the use of acupuncture for hot flushes associated with hormonal treatments for cancer would be worthwhile as these patients form the bulk of referrals and many reported improvement in their hot flushes. A pilot study to compare acupuncture and Venlafaxine for hot flushes in breast cancer patients taking anti-oestrogen treatment is currently being planned. The results of this study demonstrate that acupuncture may benefit patients experiencing anxiety and/or fatigue associated with cancer. A larger randomised controlled trial would more adequately investigate this hypothesis.

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.

Background: The role of radiotherapy for large and locally advanced non-melanoma skin cancer is unclear. In this report, we aimed to review our institutional experience with patients treated with radiation therapy for T2–T4 NMSC and analyze outcomes.

Methods: Seventy patients and 85 lesions were reviewed who received radiotherapy. Fifty-six lesions (65.9%) were untreated, 17 (20.0%) recurrent, and 12 (14.1%) post-operative. Forty-three (50.6%) were staged T2, 20 (23.5%) T3, and 22 (25.9%) T4. Median follow-up was 20 months.

Results: Thirty-nine living patients (59.0%) had no evidence of disease, of which 35 (89.7%) required no therapy following radiotherapy. Twenty-seven patients (41.0%) died, of which 10 deaths were attributed to disease progression. Achievement of complete response (CR) to all therapy and radiotherapy alone was, respectively, 95.3% and 86% for T2, 70% and 65% for T3, and 68.2% and 59.1% for T4. Statistically significant factors for CR included basal cell histology (p = 0.005) and tumour stage T2 (0.01).

Conclusions: Radiotherapy for T2–T4 NMSC is effective. Basal cell histology and T2 are statistically favoured to achieve CR to radiotherapy alone.

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.

In prostate permanent implants using 131Cs seeds, the prostatic edema developed during the implantation procedure, increases the separation between the seeds. This leads to a decrease in the prostate coverage and thus causes an edema induced dose reduction, which results in an increase in tumour cell surviving fraction (SF) with a corresponding decrease in tumour control probability (TCP). To investigate the impact of edema on the SF and the TCP, the expression of the SF of the linear quadratic (LQ) model was extended to account for the effects of edema using the exponential nature of edema resolution and the dose delivered to the edematous prostate. The SF and the TCP for edematous prostate implants were calculated for 31 patients who underwent real time 131Cs permanent seed implantation. The dose delivered to the edematous prostate was calculated to compute the SF and the TCP for these patients for edema half lives (EHL) ranging from 4 days to 34 days and for edemas of magnitudes (M0) varying from 5 to 60% of the actual prostate volume.

A reduction in the dose delivered to the edematous prostate was found with the increase of EHL and edema magnitude which results in an increase of the SF, and corresponding decrease in the TCP. The dose reductions in 131Cs implants varied from 1.1% (for EHL = 4 days and M0 = 5%) to 32.3% (for EHL = 34 days and M0 = 60%). These are higher than the dose reduction in 125I implants, which vary from 0.3% (for EHL = 4 days and M0 = 5%) to 17.5% (for EHL = 34 days and M0 = 60%). As edema half life increased from 4 days to 34 days and edema magnitude increased from 5 to 60% the SF increased by 4.57 log, and the TCP decreased by 0.80. Compensation of edema induced increase in the SF and decrease in the TCP in 131Cs seed implants should be carefully done by redefining seed positions with the guidance of post-needle plans. The presented model in this study can be used to estimate the SF or the TCP for pre plan or real time permanent prostate implants using day 0 post-implant CT images.

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: Medical device performance checks are essential following changes to control system software. This work investigates the effects of new software on the performance of a high dose rate (HDR) brachytherapy treatment unit.

Methods and Materials: A performance assessment was undertaken of the Eckert & Ziegler BEBIG GmbH MultiSource® HDR treatment unit following software upgrade. Video recordings of source transits were used to calculate transit doses, and autoradiography used to measure source dwell positions. Results were compared to a previous study.1

Results: All results showed improved performance with the new compared to old control software. Optimal source movement profiles were observed with maximum transit speeds of 63 (+/−4) mm s−1 between dwells of 5.0 mm separation. The maximum error in transit dose correction with the new software was 2.5 % at 10.0 mm perpendicular from the source axis, compared to 5.6 % previously. The new software eliminated a causal relationship between curvature of the source transfer tubes and dwell position uncertainty.

Conclusions: This work demonstrates the need for comprehensive medical device system checks following software changes. Technical improvements in HDR device performance have been achieved with the new software; reducing transit doses, improving transit dose correction, and improving source positioning accuracy.