Current Perspectives on the Evolving Role of Radiation Therapists – Highlights from ESTRO23

1. Introduction

Previously, it was believed that about half of all cancer patients would undergo radiotherapy (RT) at some stage of their treatment journey. However, the scope and applications of RT are currently broadening (1). Clinical oncologists make the treatment indication, while the daily administration is the responsibility of Therapeutic Radiographers/ Radiation Therapist, hereafter referred to as Radiation Therapy Technologists (RTTs). The RTTs are the only professionals who can legally turn the beam on and deliver the treatment, but their responsibilities extend beyond machine operation. They represent a specialised branch of allied health professions demanding advanced tertiary education and substantial clinical experience.

In certain countries, such as the UK, the RTTs are the exclusive group to pursue dedicated undergraduate studies in radiotherapy and oncology. Nonetheless, there are educational discrepancies across Europe. The care of radiotherapy patients is a collaborative effort involving various professionals from the initial diagnosis through treatment planning, delivery, on-treatment monitoring and post-treatment phase. However, RTTs have the unique privilege of engaging with patients daily throughout their treatment journey. This places them at the forefront of cancer care, uniquely positioned to provide consistent patient support and ongoing care.

Radiation oncology is an evolving medical field marked by technological progress, particularly in computer science and machine learning. RTTs are adapting to changes in treatment delivery methods and need to continuously update their knowledge and skills (2).

This manuscript represents a perspective on the evolving role of RTTs in the context of current changes in technology and holistic patient approach, including some highlights from the European Society for Therapeutic Radiology and Oncology (ESTRO) annual meeting.

2. Recent developments and their impact

2.1. Evolution of RTTs’ role

The central theme of the ESTRO congress in 2023 was “From Innovation to Action”, sparking in-depth discussions encompassing numerous aspects of incorporating AI into clinical radiotherapy practices. The possibility that Artificial Intelligence (AI) will replace specific tasks traditionally performed by RTTs remains a topic of active deliberation.

AI can improve the delivery of RT in many of the treatment stages: contouring of the organs at risk and target volumes, dose calculation and quality assurance. Specifically trained AI algorithms could also assist in automatic patient setup and positioning by analyzing imaging data or continuously monitor patients during treatment, analyzing changes in anatomy and suggesting adapted treatment plans. The AI could also assist the RTTs in recommending patients personalized education materials for improving patients’ understanding and compliance. Being able to analyze large volumes of patient data, AI has the potential to contribute to workflow optimisation and subsequently a better resources utilisation. It can also contribute to research, by identifying patterns, treatment response and outcomes, which could determine changes in the current approaches. Rather than a replacement, it is much more probable that AI will function as a complementary tool, aiming to streamline and facilitate the responsibilities of RTTs, similar to an additional team member. Therefore, it becomes important to provide the RTTs the appropriate education on AI and involve them in discussion in this topic. According to a recent survey assessing the Irish RTTs’ opinion on AI, almost half of the respondents anticipated reducing staff levels with AI, and a similar percentage already used AI-based solutions. However, 70.6% felt AI would be positive for the patients, and 94% favoured AI implementation (3).

The optimisation of clinical workflows and ensuring efficiency in service delivery relies on collaboration between RTTs, treatment planning system vendors, and manufacturers of treatment and imaging technologies. As technological systems advance, a continuous educational framework is needed. Empowering therapists to thrive in this dynamic environment requires active participation in research endeavours, including a broader engagement in domains such as AI and Image Guided Adaptive RT.

Within the clinical decision-making process, RTTs should possess an innate ability to make independent determinations regarding immobilisation selection and the acquisition of pre-treatment scans. Integrating these emerging subjects into professional education reflects the ever-evolving landscape of radiotherapy (4).

2.2. Image Guided Radiotherapy and Adaptive Radiotherapy

In slightly over a decade, Image Guided Radiotherapy (IGRT) became part of the current practice (5). Image quality increased and made it possible to visualise the targets and organs at risk more precisely. Bony anatomical surface landmarks positioning has been replaced by kV and MV images, cone-beam CT and more recently by real-time MRI, 4D CT, use of fiducial markers or surface-guided systems (6).

Professional Societies’ joint efforts resulted in updated recommendations clearly stating the RTTs role as multidisciplinary team members and the need for adequate training and clear procedures. “On target 2”, for example, is a report that provides updated recommendations for the application of imageguided radiotherapy and to enable future implementation of four-dimensional (4D) adaptive radiotherapy. The main recommendations refer to many practical aspects, such as the integrative approach of the entire patent pathway and adapted process in terms of imaging frequency and dose. The importance of effective immobilisation is also underlined, as well as the necessity of place-specific protocols. Routine prospective data collection and analysis is considered essential to identify systematic or random errors and the most appropriate values for margins. Participation in clinical trials is encouraged to develop and implement IGRT protocols (7).

Adaptive Radiotherapy (ART), a recent development, implies changing the RT plan as a result of changes in the target position, due to tumour volume variations, weight loss or intrafractional movements, as organs’ internal motion (8). There are two strategies for adapting the treatment plan. One implies choosing for a “library of plans”, approximating the best fit of planning target volumes (PTV), based on an onboard cone beam CT (CBCT). Another option is the daily adaptation of the treatment plan based on CBCT or MR, with the patient on the treatment couch, also named online adaptive radiotherapy (9). Reviewing, editing and accepting the contours for target volumes and organs at risk is traditionally the responsibility of physicians. However, while more patients receive online ART, especially with the increased use of hypofractionated schedules, there is a shift towards an RTT-led workflow (10). Two reports from the Netherlands showed that a comprehensive training program allowed RTTs to independently treat prostate cancer patients. One of the programs allowed the delivering of 1000 fractions with only 5 requests of physician’s intervention (11). In the the second one, 94% of the 150 RTTs’ contours for MRI guided ART were clinically acceptable (12).

However, these enhanced treatment modalities have specific considerations: prolonged appointment times, the essential involvement of the entire multidisciplinary team (including radiation oncologists and physicists), and modified patient expectations. Patients must be informed before treatment starts regarding the treatment process (involving various personnel in the workflow) and their roles (such as engaging in training exercises for controlled breathing). Therapists can provide written materials, organise informative sessions, or develop radiotherapy-related videos/presentations to facilitate comprehension. The primary goal of patient education revolves around mitigating anxiety or concerns while enhancing their understanding of the procedure.

Patient selection criteria are integral to the ART process, as careful screening assesses patient performance, compliance and potential contraindications. Self-report measures can be used to predict the risk of RT session disruption due to anxiety (13). Patient positioning is directly impacting ART. Since real-time adaptive treatment sessions inherently require more time than standard RT fractions, RTTs must ascertain the patient’s capability to sustain stable and comfortable positions to ensure minimal patient movement during treatment. Effective communication with patients is required throughout the adaptive RT sessions, so the RTT must ensure the technical functionality of intercom systems for in-treatment communication and the development of communication skills needed in patient interaction (14).

Accurate collection of data regarding treatment and patient’s feedback It is the responsibility of the RTTs, who need to collect this information in a way that reflects the patients point of view but also has the also scientific rigor, so the data can be analysed. Therefore RTTs need a certain amount of research education so that they can appropriately undertake such projects. RTTs’ involvement in research activities should be encouraged and supported by educational and practical interventions. for the benefit of the patients and the multidisciplinary team. As discussed also during the ESTRO 2023 session, “Education is the RTTs superpower”.

2.3. Surface Guided Radiotherapy (SGRT)

Over the past few years, the clinical utilisation of SGRT has gained widespread adoption, encompassing various techniques and treatment sites. This technology, relying on optical surface scanning, has been integrated into clinical protocols, necessitating comprehensive guidance for its implementation across diverse treatment scenarios.

An international survey on current clinical practice published in 2022 gathered data from 278 institutions and reported that half were using SGRT. The main clinical application was patient positioning, motion management, and deep inspiration breath hold. The perceived drawbacks to broader application were financial, logistic and insufficient data on clinical value (15). Recognising this need, ESTRO has provided guidelines that involve staff member roles and responsibilities. The ES-TRO-ACROP guidelines also address procedure challenges and outline potential system failure scenarios. Institutions implementing SGR are advised to follow the guidelines to ensure the proficiency of each staff member in every step of the workflow (16).

An ESTRO 2023 presentation by Filipe Moura on the clinical implementation of SGRT presented results from the survey, the main current recommendations and some interesting data on system capabilities. Position changes of 1 mm or 1 degree can be identified using SGRT, and the possibility of a thermal map also exists for some systems. Templates and adapted protocols for different anatomic sites are needed for optimising the workflow. While daily imaging remains essential, SGRT has the potential to expedite image registration and reduce the need for frequent imaging, ultimately streamlining the treatment process (17).

Since RTTs are pivotal in patient preparation, positioning, monitoring, and treatment administration, training sessions and continuous education are indispensable to avert potential errors and suboptimal technology usage. Regular quality assurance tests, from daily or weekly checks to monthly or annual evaluations, uphold the system’s integrity. While daily imaging remains essential, SGRT has the potential to expedite image registration and reduce the need for frequent imaging, ultimately streamlining the treatment process (18).

The field is persistently advancing towards novel methods of assessing not only precise positioning but also the surfaces exposed to radiation during treatment. A recent promising breakthrough involves the utilization of a time-gated three-channel camera, which captures the broadband light emitted due to the Cherenkov Effect. (19).

2.4. Positioning, immobilisation and patient comfort

Positioning and immobilisation of patients are crucial for reproducible and accurate delivery of radiotherapy to ensure tumour control and avoid healthy tissue toxicity. An essential role in position holding and compliance with treatment plans in radiotherapy is patient comfort.

A systematic review by Goldsworthy et al. analysed 46 randomised controlled trials which evaluated 13 types of comfort interventions grouped into four categories: audio-visual, physical, psychological, and “others” (education/information, aromatherapy). Most aromatherapy interventions, one audio-visual and one educational intervention, improved patient comfort based on anxiety levels and were considered clinically significant (20).

A notable presentation at ESTRO underscored the imperative of prioritising patient comfort within radiation therapy and delineated several strategies to alleviate anxiety, minimise discomfort, and enhance the overall patient experience. In his presentation titled “Role of music and ambient light and their impact on patients’ immobilisation and verification,” Philipp Scherer highlighted that despite comprehensive patient education, a subset of patients still experience anxiety and discomfort after the commencement of radiotherapy. The study involved 190 patients and revealed that dimmed light treatment rooms and relaxing music positively affected patient relaxation. Changes in anxiety levels due to the colour of the treatment room were not reported to be significant, and there was no interference between the coloured light and surface guidance systems or between the background music and intrafraction movement or communication through the intercom system (21).

Given their regular interaction with patients during RT sessions, RTTs possess a unique vantage point to assess and address patients’ needs and concerns. Beyond their technical responsibilities in treatment planning and delivery, RTTs offer patients crucial information and reassurance regarding treatment expectations and potential side effects. While assessing the breast cancer patients’ perspectives, one study concluded that forming a good relationship with the RTTs and gaining information about their treatment increased their emotional comfort during RT (22). Mattarozzi et al. observed a noteworthy connection between patient satisfaction with the rapport established with RTTs and patients’ perception of the intensity of pain induced by radiation therapy, as well as their overall attitudes toward the treatment process. The patients who perceived their interaction with RTTs as positive reported reduced pain intensity and had a more favourable disposition toward the entire RT experience (23). After analysing twelve papers in a systematic review by O’Neil et al., a similar conclusion was stated. The need for sufficient time spent with RTTs and the preference for continuity of RTTs during treatment positively influenced patients’ perspectives (24).

An interesting qualitative study brought together both the patients’ and the RTTs’ points of view on comfort during RT. Both categories mentioned emotional health-related issues like stress, vulnerability and privacy and positioning/immobilisation-related experience. Information and communication were mentioned by patients only, as well as environmental experience determined by the first impression of treatment rooms (25).

Recognising the role of the holistic approach underlines the need for RTTs supplementary training, which could enhance communication and interpersonal proficiencies, a deeper understanding of patient psychology, and an increased emphasis on emotional intelligence. European Society for Radiotherapy and Oncology’s core curriculum for RTTs includes the required knowledge and skills for advanced delineation and volume determination, treatment planning, imaging, quality and risk management, brachytherapy, management and service development, patient care and support, and research (18).

3. Conclusion

Recent technological improvements in the RT field, like IGRT, ART, SGRT and AI-based solutions, are bringing the opportunity for RTTs to grow and develop their role in the multidisciplinary team. Educational interventions empower the RTTs to improve their skills, deliver quality treatment, efficiently educate patients and contribute to RT research.

Abbreviations:

RTT – radiation therapy technologist

RT – radiation therapy

IGRT – image-guided radiotherapy

ART – adaptive radiotherapy

SGRT- surface-guided radiotherapy

AI – artificial intelligence

ESTRO – European Society for Therapeutic Radiology and Oncology

CT – computed tomography

MRI – magnetic resonance imaging

Statements:

Author’s contributions: EMV, NKV and MEC selected the material, EMV and MEC wrote the text. JvdB reviewed and improved the manuscript.

Consent for publication: As the corresponding author, I confirm that the manuscript has been read by and approved for submission by all authors.

Funding: This study did not receive any specific grant from the funding agencies in the public, commercial, or not-for-profit sector.

Conflicts of Interest: The authors declare no conflict of interest.

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