03.02.01. Adapting and responding to treatment plan deviations
Radiation therapists are alert to deviations that affect a patient’s treatment plan and communicate them to the appropriate members of the healthcare team
Attention to changes that affect radiation therapy
- The goal of radiation therapy is to irradiate the tumour volume while minimizing radiation to the surrounding critical structures.1
- Changes that occur over the time that it takes to administer radiation therapy can affect the original treatment plan and/or the treatment intent.
- As a point of contact with the patient, radiation therapists have an important role to play in the recognition of these changes2
- Radiation therapists remain alert to these changes throughout their interactions with patients, which include but are not limited to, changes to:
- Target position and shape (e.g., tumour regression or growth, bladder filling and rectal distension)3
- Anatomic structures (e.g. volume, motion changes)4
- Patient weight gain and/or weight loss
- Reproducibility of the set up
- Treatment intent (e.g., from radical to palliative)
- Fractionation
- Accessories used for treatment
- Side effects2
Tolerance parameters
- Each facility, under the direction of the radiation oncologist, should consider establishing a threshold of couch positioning changes above which the physician is required to review the patient setup and images before treatment is delivered.5,6,7
- Radiation therapists should be familiar with the thresholds identified in such a plan and understand the procedures to respond to changes that exceed defined thresholds.
- Methods are in place in each radiotherapy department to detect and act on changes that exceed the determined thresholds over the course of a radiation treatment.3
- In order to maintain the integrity of treatment, radiation therapists undertake thorough assessment of the treatment plan with systematic quality checks:
- Systematic geometric and dosimetric verification is used to ensure that the right radiation dose is being delivered to the right target3
- Information from imaging is used to identify anatomic changes
- Ongoing evaluation of immobilization/repositioning systems is in place to ensure stability and reproducibility of the plan
Response to deviations
- All changes or deviations require documentation and further discussion with the healthcare team, whether they are within tolerance parameters or not.6
- It is important for radiation therapists to note changes in patient separation/ position/anatomy that could result in the need for a prescription adjustment
- Changes in the patient’s condition (i.e., weight loss, tumour shrinkage, etc.) that could affect the treatment plan are noted
- Findings are most effectively communicated as straight fact (e.g., reported signs/symptoms, measurements from imaging: tumour 1cm larger).
- It is beyond the scope of radiation therapist practice to make diagnostic interpretations or conclusions from this information2
- Changes or deviations that might affect a patient’s treatment plan are communicated directly to the appropriate members of the patient’s healthcare team.
- Modifications to a patient’s treatment plan are made in consultation with the radiation oncologist and all appropriate members of the patient’s healthcare team1
- Radiation therapists should not unilaterally make changes to the treatment plan without consultation
- In the event a patient enquires about a change or delay to treatment, radiation therapists should refrain from making interpretative or diagnostic comments, but simply state the facts and explain the consultation process that will occur.8
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References
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Gomez D, Chang J. Adaptive radiation for lung cancer. J Oncol. 2011;2011(2011). DOI: http://dx.doi.org/10.1155/2011/898391
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American Society of Radiologic Technologists. The Practice Standards for Medical Imaging and Radiation Therapy. ASRT. June 2017. Available from: https://www.asrt.org/docs/default-source/practice-standards-published/ps_rt.pdf?sfvrsn=2. [Accessed 27 Nov 2017]
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The Royal College of Radiologists, Institute of Physics and Engineering in Medicine, Society and College of Radiographers. On target: ensuring geometric accuracy in radiotherapy. RCR. Nov 2008. Available from: http://www.rcr.ac.uk/docs/oncology/pdf/BFCO%2808%295_On_target.pdf. [Accessed 24 Nov 2017]
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Lu J, Ma Y, Chen J, et al. Assessment of anatomical and dosimetric changes by a deformable registration method during the course of intensity-modulated radiotherapy for nasopharyngeal carcinoma. J Radiat Res. 2014;55(1):97–104. DOI: https://doi.org/10.1093/jrr/rrt076
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American College of Radiology. ACR–ASTRO Practice parameter for image-guided radiation therapy (IGRT). ACR.
2009. Updated: 2014. Available from: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/IGRT-RO.pdf?la=en. [Accessed 11 May 2018] -
Canadian Partnership for Quality Radiotherapy. Quality Assurance Guidelines for Canadian Radiation Treatment Programs. CPQR. Dec 2015. Available from: http://www.cpqr.ca/wp-content/uploads/2013/09/QRT2015-12-03.pdf. [Accessed 24 Nov 2017]
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Franks KN, McNair HA. Implementation of Image-guided Radiotherapy. J Clin Oncol. 2012;24:625-626.
DOI: http://www.clinicaloncologyonline.net/article/S0936-6555(12)00178-1/pdf. -
Canadian Association of Medical Radiation Technologists. Sharing Personal Opinions with Patients. CAMRT, Best Practice Guidelines. Nov 2015. Available from: https://camrt-bpg.ca/patient-management/patient-interactions/sharing-personal-opinions-with-patients/. [Accessed 24 Nov 2017]