Session Item

IGRT in gynaecological cancer treatment can be challenging due to the complexities presented by variations in target and OAR position. Referral online to departmental IGRT advanced practitioner radiographers (IGRT APRTT) represents an initial escalation when issues are detected by treatment RTTs. Decision making by IGRT APRTTs can be subjective and introduces a level of uncertainty during the online IGRT process. The most important decision is whether to stop the treatment workflow and intervene or continue to treat. The clinical gynaecological team within the authors department acknowledged this and wanted to provide robust protocols that would aid decision making for IGRT APRTTs in online scenarios. The aim of this audit was to evaluate the effectiveness of the developed framework.

30 consecutive radically planned cervix and endometrial patients were selected for retrospective review. Departmental protocol is to image daily. All relevant XVI images, defined as when the treatment workflow was halted and patient taken off the treatment couch, were reviewed by the clinical gynaecological team to consider if the intervention was necessary or whether treatment should have continued. Based on their judgements thematic trends were categorised and a decision making framework was constructed to cover common scenarios with recommended actions dependent on thresholds and established action levels based on severity:
•    Green - proceed to treat

•    Amber- proceed to treat with intervention offline

•    Red - do not treat.

The framework was introduced to the IGRT APRTT team after stakeholder approval. Once established a further 30 consecutive patients were sampled to assess the effect of implementation of repeat imaging. No further changes within the department were made that might influence IGRT review.

30 cervix and endometrial patients were included in the study before and after introduction of the IGRT APR decision making framework. Prior to the introduction of the framework treatment workflows were interrupted and the patient rescanned for 14% of fractions (101/721). This reduced to 7.3% (53/730) after the framework was implemented, representing a reduction of 48%. The primary justifications for rescans prior to implementation were larger rectum (44.6%/45) and smaller bladder volume (35.6%/36). After implementation the main justifications given were smaller bladder volume (52.8%/28) and larger rectum (26.4%/14).

The development and implementation of a clinician-directed IGRT APR decision making framework leads to a significant reduction of on-treatment XVI rescans for gynaecological radiotherapy treatment. The framework has augmented the IGRT APRTT skillset, helped standardise actions and reduce uncertainty, improved on-treatment efficiency and reduced the number of imaging exposures delivered to patients. The project has provided a template for developing similar decision making matrices for other complex IGRT sites/techniques e.g. head and neck and SABR.