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In August 2020 we became the first radiotherapy centre in the UK to introduce CBCT-guided online Adaptive Radiotherapy (oART) using Varian’s ETHOS platform. We aspired to introduce this as the standard of care for anatomical sites such as bladder and prostate where conventional IGRT cannot account for daily changes in anatomy. We began with clinicians leading the online review of all treatment fractions alongside an MDT team of RTTs and physicists. It became clear that workforce availability had led to a reduced uptake in the use of oART compared to our expectations. We therefore looked to the wider skill set within the multiple disciplines of the department and established that an RTT, with some additional training, would be able to lead the oART workflow. This has enabled us to offer oART to many more patients. Here we describe and evaluate the training process we have developed.

A clinical portfolio allowed each aspect of the adaptive process to be assessed.  Firstly, RTTs must identify any previous experience that is relevant to the role such as planning experience or soft tissue contouring. A minimum of 3 online adaptive treatments were then observed to gain an understanding of the workflow.  

RTTs then undertake supervised adaption competencies on a training emulator system followed by real-time fractions. Each RTT will thus be supervised over a minimum of 5 practice and 10 real-time fractions, of both bladder and prostate treatments. After successful training the RTT is delegated tasks, according to UK IRMER regulations; these are organ and target review, plan selection, and plan approval. RTTs also receive PSQA training on MOBIUS 3D. We also require RTTs who will lead the adaptive process to review the clinician-approved scheduled plan prior to treatment. They must also ensure that appropriate handover has been documented from the clinician, however the clinician still maintains overall responsibility for each patient.

We have used this program to train 5 RTTs and 2 members of the physics team. The process continues to be reviewed and an in-house presentation suited to both RTT and physics staff has been developed to allow future roll out. We continue to have a clinician present for the first fraction, but all other oART fractions for urological cancer is now RTT-led.  

To date, 196 fractions for 12 patients with urological cancer have been RTT-led, CBCT-guided oART. All bar one fraction was treated using an adapted plan. No additional clinician input has been required following the initial delegation to RTT-led treatment any of the cases.

It is feasible to train RTTs to lead the oART process. This is particularly true in the CBCT-guided setting due to the extensive experience RTTs already have with IGRT and soft tissue matching. This has led to many more patients being offered oART within our department and we hope to roll out training to more anatomical sites as we continue to evolve our adaptive program.